Healthcare Provider Details

I. General information

NPI: 1992135933
Provider Name (Legal Business Name): STACY MARIE DEROSA R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 17TH AVE
SAN FRANCISCO CA
94121-2312
US

IV. Provider business mailing address

355 17TH AVE
SAN FRANCISCO CA
94121-2312
US

V. Phone/Fax

Practice location:
  • Phone: 631-882-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1018194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: